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PubMed1981

Combination use of nonsteroidal antiinflammatory drugs.

Polypharmacy with nonsteroidal antiinflammatory drugs (NSAIDs) is widely practiced despite being condemned by many rheumatologist. Combination use of aspirin with other NSAIDs might be discouraged for three well-documented reasons. First, aspirin reduces the blood levels of many NSAIDs. Second, multiple drugs are antagonistic or at least less than additive in animal models of inflammation. Third, there is no good clinical data to suggest that combination use of NSAIDs is beneficial. Unless new studies become available, NSAIDs should be used one at a time, with supplementary analgesics added on a prn basis.

Analgesics↗
PubMed1984

The role of the pharmacist in a geriatric nursing home: a literature review.

This review delineates the pharmacist's controversial clinical role in nursing homes as it has developed within the legal, social, and economic climate of the Medicaid and Medicare conditions of participation. Special problems of the geriatric institutionalized patient include polypharmacy, adverse reactions, the overuse of prn drugs, and inadequate physician contact. These problems are compounded by an impoverished scientific data-base for appropriate drug use in the aged. Studies that clarify the impact consultant pharmacists have on the number of drugs prescribed, adverse reactions, and cost containment are compiled and evaluated. It is shown that pharmacists can reduce the number and cost of drugs. Physician acceptance of pharmacists' recommendations was found to be at least 60 percent in these reports. Well-controlled studies are lacking in the literature.

Aged↗
PubMed1990

A profile of alcohol and prescription drug abuse in a high-risk community-based elderly population.

Substance abuse among the elderly is relatively common but often remains undetected or ignored by health and social workers. Psychosocial and health factors related to the aging process are the major contributors to alcoholism and other drug abuse. It is estimated that between two and ten percent of individuals over the age of 60 suffer from alcoholism. This article profiles alcohol and prescription drug abuse among the geriatric clientele of Elderly Services of Spokane (ESS), a division of the Spokane (Washington) Community Mental Health Center. In addition to traditional channels, ESS uses a unique gatekeeper network to identify high-risk, community-based elderly. Elderly persons referred by gatekeepers are regarded as "hidden" elderly and at highest risk; notably, 37 percent of ESS clients are referred via this mechanism. Case management records of 1668 ESS clients were reviewed for a history of alcoholism, and a total of 161 persons (9.6 percent) were diagnosed with either primary or secondary alcohol abuse. Fifty subjects (about five percent of the average active ESS caseload) were referred for prescription drug abuse. Misused prescription drug classes were sedative-hypnotics, antianxiety agents, and analgesics. Diazepam, codeine, meprobamate, and flurazepam were the top four agents, and 92 percent of the subjects were found to have a duration of prescription drug abuse in excess of five years. A 60 percent correlation between prescription drug abuse and previous or active alcoholism was found. Additional characteristics of the geriatric study population are discussed in detail, including specific psychosocial factors, source of referral, age, gender, living situation, marital status, psychiatric history, and presence of polypharmacy.

Aged↗
PubMed1991

Prescribing patterns in primary healthcare in Saudi Arabia.

A systematic sampling of prescriptions from primary care centers in the Al-Baha region of Saudi Arabia was analyzed to determine the patterns of drug prescribing and the compliance of practicing physicians in these centers with the essential drug list issued by the Ministry of Health. The average number of drugs per prescription was 2.3 +/- 0.7 of which 86.5 percent of the prescriptions contained two to three drugs. In 53.7 percent of the prescriptions no duration for treatment was specific and 96.5 percent of the prescriptions did not indicate drug strength. The study showed that analgesics and vitamins were the two most common classes of drug prescriptions in the centers and that 18.6 percent of prescribed drugs were not from the allowed list of drugs. The causes of polypharmacy and noncompliance with the limited list are discussed with emphasis on the essential drug list as a method of rationalizing prescribing in primary healthcare.

Aged↗
PubMed1995

Prescription drug and healthcare use among Swedish patients treated with antidepressants.

OBJECTIVE: To analyze healthcare and prescription drug use among patients taking and those not taking antidepressant drugs in a Swedish community. DESIGN: Cross-sectional study. SETTING: General population of the rural Swedish municipality Tierp of approximately 20,000 inhabitants. PARTICIPANTS: All residents of Tierp aged 25 years or older during 1988. MAIN OUTCOME MEASURES: Mean number of ambulatory care visits, hospital bed days, and prescriptions per person; proportion of those taking prescription drugs in different pharmacologic classes. RESULTS: Patients treated with antidepressant drugs had a significantly (p < 0.05) greater use of ambulatory care, hospital care, and prescription drugs than those who did not take antidepressants in the study population. They also had an increased frequency of use of prescription drugs from virtually all pharmacologic classes. Furthermore, the risk for polypharmacy was high in patients treated with antidepressant medications. CONCLUSIONS: Those who took antidepressant drugs consumed more health services and prescription drugs than did those not taking an antidepressant. Patients receiving antidepressant treatment may be at serious risk for iatrogenic disease and should be evaluated carefully with respect to concomitant drug use.

Adult↗
PubMed1996

Use of prescription medications in an elderly rural population: the MoVIES Project.

OBJECTIVE: To determine the pharmacoepidemiology of prescription drug use in a rural elderly community sample, specifically the numbers and categories of medications taken and the factors associated with them. DESIGN: Cross-sectional community survey. SETTING: The mid-Monongahela Valley of southwestern Pennsylvania. PARTICIPANTS: An age-stratified random sample of 1360 community-dwelling individuals, aged 65 years and older. MEASURES: Self-reported use of prescription drugs demographic characteristics, and use of health services. RESULTS: Nine hundred sixty-seven participants (71%) reported regularly taking at least one prescription medication and 157 (10%) reported taking five or more medications (median 2.0, range 0-13). Women took significantly more medications than men (median 2.0, range 0-13 and median 1.0, range 0-9, respectively; p = 0.01). The use of a greater number of medications was independently and statistically significantly associated with older age, hospitalization within the previous 6 months, home health care in previous year, visit to a physician within the previous year, and insurance coverage for prescription medication. Individuals older than 85 years were significantly more likely to be taking cardiovascular agents, anticoagulants, vasodilating agents, diuretics, and potassium supplements. Significantly more women than men were taking nonsteroidal antiinflammatory drugs, antidepressants, potassium supplements, and thyroid replacement medications. CONCLUSIONS: Both the number and the types of prescription medications vary with age and gender. The demographic and health service use variables associated with greater medication use in the community may help define high-risk groups for polypharmacy and adverse drug reactions. Longitudinal studies are needed.

Age Factors↗
PubMedDate not supplied

Guidelines for the treatment of elderly cancer patients.

BACKGROUND: The management of elderly patients with cancer is influenced by several factors that can vary widely among aging individuals. As the proportion of elderly individuals increases, the need for specific care guidelines for this population is critical. The National Comprehensive Cancer Network (NCCN) has developed guidelines to address these factors when formulating optimal treatment regimens for elderly patients and to avoid significant toxicity and maintain their quality of life. METHODS: Factors that influence the appropriate treatment choices for the elderly, such as functional status, comorbidity, polypharmacy, and the presence of anemia, are reviewed, and the guidelines developed by the NCCN for treatment elderly patients are discussed. RESULTS: The guidelines address these factors when defining the goal of therapy and formulating individualized treatment approaches for the elderly to provide optimal care for these patients, avoid significant toxicity, and maintain their quality of life. CONCLUSIONS: The goal of therapy must be clearly defined, whether survival, remission, cure, or palliation of symptoms. Enrollment of elderly cancer patients onto clinical trials is encouraged so the guidelines can be validated.

Aged↗
PubMed2006

Pharmacogenomics, informatics, and individual drug therapy in psychiatry: past, present and future.

The modern era of psychopharmacology began in the 10 year period from the late 1940s to the late 1950s. During this period, the first antidepressants, antipsychotics, anxiolytics and mood stabilizers were all discovered. In the 1960s, the pharmacology of these drugs was elucidated and theories about the mechanisms of action proposed. In the 1970s and 1980s, new, more selective compounds were developed based on improved structure-activity relationships derived from in vitro receptor binding studies and animal models. These compounds entered clinical testing in the 1980s and began to be marketed in the late 1980s and 1990s. All of these agents were approved to treat psychiatric syndromes which are conditions defined by a cluster of signs and symptoms. None of these agents was developed based on an understanding of the pathophysiology of the illnesses being treated. None of these agents are curative and virtually all have limited clinical efficacy. In the earliest days of the modern era, there were few drugs available to combine and many had such broad actions that they were often marginally tolerated or unsafe when used in combination (tricyclic antidepressants and monoamine oxidase inhibitors). With the advent of more medications, the frequency and extent of polypharmacy has exploded. In addition to simply having more drugs from which to select with different pharmacological profiles, many newer medications are also more selective in their pharmacological actions and thus are often better tolerated and safer when used in combination. In addition, there is the concern that the trade-off for more selective pharmacology may have been better tolerability at the expense of reduced efficacy, which clinicians then compensate for by using more medications in combination. For all of the above reasons, polypsychopharmacology has been present from the beginning of the modern era of psychopharmacotherapy and continues to be the rule rather than the exception. In fact, the frequency and the complexity of such polypsychopharmacology are both enormous and increasing. The percentage of patients being discharged from the Biological Branch of the National Institute of Mental Health on more than three psychiatric medications increased more than ten times between 1974-79, and 1990-95. The majority of patients seen in the Veterans Administration Medical System in the United States are on unique combinations of medications and the frequency and complexity of such polypharmacotherapy is increased in patients on psychiatric medications. Throughout the modern era, there have been attempts to determine whether there are populations of patients selectively responsible to specific agents (e.g. serotonin versus norepinephrine reuptake inhibitors). However, no compelling data have so far emerged. Instead, clinicians generally resort to combining drugs on the basis of symptoms such as psychosis and depression or anxiety and depression. Science has primarily informed the clinician about safety concerns rather than efficacy concerns when using such combinations. That will change in the future with a better understanding of the pathophysiology of psychiatric illnesses which in turn will lead to improved therapies and the potential for more rationally derived combination treatments.

Clinical Trials as Topic↗
PubMed1975

Elderly people's compliance with prescriptions, and quality of medication.

We set out to examine how quality of medication influenced patients' use of drugs. 217 elderly people living in homes for the aged in Helsinki were interviewed. They used a considerable number of prescribed drugs: one-third of them had ingested at least four different prescribed drugs during the previous week. This polypharmacy largely concerned symptomatic drugs. Non-compliance with prescription instructions was common, and was more common with the symptomatic drugs. The number of deviations from the instructions correlated positively with the number of drugs, especially the number of symptomatic drugs. According to this study, non-compliance with prescription instructions is not to be condemned as such. In so far as drugs are prescribed in unreasonable large quantities, underuse is a way for the patient to avoid ingesting excessive quantities of drugs.

Aged↗
PubMed1988

Intractable epilepsy: etiology, risk factors and treatment.

The data emerging from our study are the following: the presence of an identifiable cause is important: complications like tuberous sclerosis or signs of marked cerebral damage represent an adverse risk factor for IE. The presence of epilepsy among relatives, evidence of pre- or perinatal cerebral damage, mental retardation, and early onset, long periods of uncontrolled seizures before starting an adequate therapy and frequency of seizures appear to be indicative of an adverse prognosis, since differences between the two groups of responsive or unresponsive patients are statistically significant. On the contrary, the occurrence of febrile convulsions in the past history does not seem to have an adverse prognosis. Temporal lobe epilepsy and IS bear the worst prognosis. ME, CPS, GTCS, SPS, LGS and PM have a progressively better outcome in responsiveness to AEDs. Concerning therapy in patients with IE, studies indicate the results of high dose monotherapy appear to be equal or better than with polypharmacy. Because of the gravity of the situation, trials with unconventional drugs have been performed, but it is too early to draw definite conclusions about the long-term usefulness of most of them. In conclusion, our data indicate that the appearance of an IE can be predicted utilizing the above mentioned criteria, considered either alone or in combination. The issue of IE remains undoubtedly an important one among the group of convulsive disorders. Further studies considering a greater number of patients and new therpeutic strategies are to be recommended.

Anticonvulsants↗
PubMed1991

Sleep spindles in epilepsy.

Spindles are a ubiquitous phenomenon in sleep, but their physiology and the effects of neurologic disorder on their frequency and amplitude are incompletely understood. We compared the incidence of three commonly defined spindle types (14-15 Hz, 12-13 Hz, and 10 Hz) and the frequency and amplitude of spindles during Stage II sleep in 50 patients with complex partial, partial and secondarily generalized, and primary generalized seizures, with and without interictal behavioral symptoms. All patients had 12-13 Hz and 14-15 Hz spindles of symmetric character in C3-A1 and C4-A2 derivations during prolonged sleep-deprived EEG recordings, which were normal except for partial or generalized epileptiform activity. Seventy-one per cent of complex partial seizure patients had 10 Hz spindles, and they occurred in 50% of the other two groups, predominating among those with interictal behavioral symptoms in all groups. Spindle frequency was significantly less in patients with generalized epilepsy than with partial seizures, and patients with complex partial seizures and partial seizures with secondary generalization differed significantly in spindle frequency. Spindle frequency was significantly lower with polypharmacy than with monotherapy. Patients whose regimens included phenobarbital had significantly lower spindle frequencies and spindle frequencies differed significantly between phenytoin and carbamazepine. Differences in spindle frequency may be due to residual medication effects, underlying encephalopathy or physiological differences between partial and generalized epilepsy.

Adolescent↗
PubMed2006

Budgetary impact of treating acute bipolar mania in hospitalized patients with quetiapine: an economic analysis of clinical trials.

OBJECTIVE: To present a tool that allows estimation of the budget impact of treatments for acute mania in bipolar I disorder from a US healthcare payer perspective. METHODS: Using discrete event simulation, the course of individuals is simulated beginning with hospitalization. Discharge depends on symptom level measured by the Young Mania Rating Scale (YMRS). The treatment effect is determined using time-dependent regression equations derived from trial data, and decision rules obtained from clinical experts. Outcomes include: time to response and symptom resolution; proportion of subjects reaching each outcome; number of adverse events. Costs were obtained from hospital discharge databases, the National Medicare Physician Fee Schedule and RedBook. Different scenarios are examined, each describing the proportion of subjects on the various treatments (lithium, divalproex sodium, olanzapine, risperidone, and quetiapine--monotherapy and in combination with lithium). Analyses are intention-to-treat over 100 days, corresponding to follow-up in mania trials. Despite its flexibility and structural adaptability, the model has some important limitations related to the characteristics of the clinical trials. These include focus on inpatient management of acute mania, use of the YMRS as the model driver, polypharmacy restricted to two-drug regimens, no explicit consideration of titration and dose changes, and relatively short time horizon. RESULTS: Scenarios with a greater proportion of quetiapine users (5% vs. 40% and 100%) result in a smaller impact on the healthcare budget (6912, 6277, and 5525 dollars per patient, respectively) and improvements in patient outcomes (e.g., 43%, 47%, and 54% responding at day 21; 74%, 77%, and 80% remitting by day 84). Sensitivity analyses showed that the budget impact is influenced by drug prices, discharge criteria and side-effect management. CONCLUSION: Results suggest that increased use of quetiapine for bipolar mania in the US is economically justified and improves health outcomes. In addition, this model illustrates that discrete event simulation is a useful and versatile tool for budget impact analyses.

Antipsychotic Agents↗
PubMed2006

Pharmacological treatment of ambulatory schizophrenic patients in Belgium.

BACKGROUND: the objective of this study was twofold:1) Describe the use of antipsychotic treatments in ambulatory patients suffering from schizophrenia in Belgium.2) Evaluate to which extend antipsychotic treatment prescribing patterns are in accordance with published treatment guidelines. METHOD: A cross-sectional survey was carried out in 16 Belgian hospitals selected from a sample of 67 hospitals. The hospitals were equally distributed between the north and south part of the country and were representative of Belgian practice. During 2 months, participating psychiatrists were asked to record the medication use as well as demographic parameters of all consecutive ambulatory patients seen at their consultation or attending a day-hospital. Data concerning 1000 ambulatory patients with schizophrenia or schizoaffective disorder were collected. RESULTS: In Belgium, the use of atypical antipsychotics is frequent (69%) in ambulatory patients with schizophrenia. In the overall sample, 73% receive only one antipsychotic drug. The majority of patients are treated with drugs of only one antipsychotic drug group, either first- typical (29.8%) or second-generation, atypical antipsychotics (53.2%). 15.8% of patients combine different types of antipsychotics. Antipsychotic dosing is adequate for the majority of patients but about one fifth receives a higher than recommended dose as per package inserts. Polypharmacy remains within reasonable limits. The use of concomitant medication varies according the antipsychotic treatment: patients who take second-generation antipsychotics only, receive the least additional drugs. CONCLUSION: Atypical antipsychotics appear to be the first line treatment for schizophrenic psychosis. Psychiatrists working with ambulatory patients are well aware of treatment guidelines and follow them quite adequately.

Journal Article↗
PubMed2006

Assessment of balance and risk for falls in a sample of community-dwelling adults aged 65 and older.

BACKGROUND: Falls are a major health concern for older adults and their impact is a significant public health problem. The chief modifiable risk factors for falls in community-dwellers are psychotropic drugs, polypharmacy, environmental hazards, poor vision, lower extremity impairments, and balance impairments. This study focused on balance impairments. Its purpose was to assess the feasibility of recruiting older adults with possible balance problems for research conducted at a chiropractic research center, and to explore the utility of several widely used balance instruments for future studies of the effect of chiropractic care on balance in older adults. METHODS: This descriptive study was conducted from September through December 2004. Participants were recruited through a variety of outreach methods, and all were provided with an educational intervention. Data were collected at each of two visits through questionnaires, interviews, and physical examinations. Balance was assessed on both visits using the Activities-specific Balance Confidence Scale (ABCS), the Berg Balance Scale (BBS), and the One Leg Standing Test (OLST). RESULTS: A total of 101 participants enrolled in the study. Advertising in the local senior newspaper was the most effective method of recruitment (46%). The majority of our participants were white (86%) females (67%). About one third (32%) of participants had a baseline BBS score below 46, the cut-off point for predicting risk of falling. A mean improvement in BBS scores of 1.7 points was observed on the second visit. For the subgroup with baseline scores below 46, the mean change was 4.5 points, but the group mean remained below 46 (42.5). CONCLUSION: Recruitment of community-dwelling seniors for fall-related research conducted at a chiropractic research center appears feasible, and the most successful recruitment strategies for this center appeared to be a combination of targeted newspaper ads and personal contact through senior centers. The BBS and OLST appear to be promising screening and assessment instruments, which might have utility in future investigations of the possible effects of chiropractic care on balance.

Journal Article↗
PubMed2004

Chemotherapy in the geriatric population.

The population in America is aging, and the number of older adults who develop cancer continues to grow. Gerontologic considerations in the delivery of health care become increasingly more important as a result of these population trends. Factors such as physiologic age-related changes, comorbid conditions, and the incidence of polypharmacy contribute to the challenges of administering chemotherapy to older patients with cancer. Age-related physiologic changes, including alterations in the gastrointestinal system, renal system, body composition, and hematopoiesis, impact patients' ability to tolerate standard doses of chemotherapy. In addition, these changes increase the likelihood of developing severe toxicities. Comorbid conditions confound the side effects of chemotherapy, and the use of multiple medications places older patients with cancer at increased risk for developing drug interactions. Older patients with cancer may be more susceptible to developing toxicities from chemotherapy, and these toxicities may be more severe. When healthcare professionals follow age-appropriate standards of oncology care, chemotherapy can be safely and effectively administered to older patients with cancer. Oncology nurses play a crucial role in assessing for potential complications and managing toxicities. Incorporating geriatric care into oncology nurses' daily practice ensures quality care for older patients with cancer.

Aged↗
PubMed1987

A comparative hospital survey of psychotropic drug prescribing.

In a survey of psychotropic drug prescribing for in-patients in three different types of psychiatric hospitals, the prevalence of combinations of more than one psychotropic drug varied from 45% in one hospital to 94% in another, with significant consistent differences between the use of drug combinations in the various hospitals. Combinations of two antipsychotic drugs were particularly frequent; the hospital with the lowest prevalence of polypharmacy was the only one with an associated psychopharmacology unit. Access to clinical pharmacology teaching may be an important factor in determining appropriate drug-prescribing habits.

Adolescent↗
PubMed1989

A comparison of in-patient and out-patient prescribing.

The prescribing of psychotropic medication to 96 attenders at a lithium clinic was compared with their prescriptions while in-patients. As out-patients, they received fewer psychotropic drugs fewer times a day. This suggests that psychiatrists do not adopt intransigent stances in favour of polypharmacy and irrational psychotropic prescribing, as previous studies have implied. Caution is advised before attributing apparently irrational prescribing to bad clinical practice, or advocating remedial action aimed at changing the habits of prescribers.

Adult↗